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Journal search - issue 4, 2004


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Paul Worley1
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1 Rural and Remote Health


31 December 2004 Volume 4 Issue 4


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ACCEPTED: 31 December 2004


Worley P.  Journal search - issue 4, 2004. Rural and Remote Health 2004; 4: 370.


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Journal Search brings Rural and Remote Health users information about relevant recent publications. This issue includes recent publications in rural health/ primary healthcare journals, worldwide, including a link to the Contents pages of a non-English language rural health journal from Norway.

Education for Health

Volume 17, Number 3 / November 2004


Journal Canadien de la Médecine Rural/Canadian Journal of Rural Medicine [in French and English]

Contents, 2004; 9: (4) Fall 2004 / Automne 2004
Issue includes:

Palliative Care: the final challenge
John Wootton, Scientific Editor

President's message: First-winter woes
Trina M Larsen Soles

Comparison of rural and urban users and non-users of home care in Canada
Dorothy A. Forbes, Bonnie L. Janzen

Introduction: Geography is considered a determinant of health because people living in rural and remote areas, compared with those in urban areas, have poorer health status and more difficulty accessing health care.
Purpose: To examine the characteristics associated with the use of publicly funded home care services among rural and urban Canadians 18 years of age and over.
Methods: The Andersen and Newman Behavioural Model of Health Services Use guided the selection of variables, analyses and interpretation of the findings. Descriptive, correlation and multiple logistic regression analyses were completed on 2 cross-sectional cycles of Statistics Canada's National Population Health Surveys.
Results and Conclusion: This research revealed that rural residents are increasingly less likely to receive personal care assistance, and rural home care users appear to have more resources (e.g., higher levels of education, sense of coherence) that likely influence their ability to access and receive home care services, than their urban counterparts. Rural residents without these resources may be less likely to receive home care services.

Adding women's voices to the call for sustainable rural maternity care
Rebecca Sutherns

The shortage of maternity care providers in Canada has been documented largely from the perspective of physicians. Women in rural communities, however, have much to contribute to this discussion. Exploratory research in 3 rural communities in south central Ontario eliciting the perspectives of 36 birthing women has affirmed the need for integrated models of maternity care. Rural women seek care that is local and "relational," characterized by time spent with care providers, continuity and personalized care. They also seek care that is based on fully informed choice. Collaborative models of care, including rural physicians, nurses and midwives, have the potential to create the sustainability and collegiality required to achieve these qualities.

Rural and remote community health care in Canada: beyond the Kirby Panel Report, the Romanow Report and the federal budget of 2003
Karatholuvu V Nagarajan

Dr. John Wootton, former Executive Director of the Office of Rural Health and now a special advisor on rural health in the Population Health and Public Health Branch of Health Canada, has said that "If there is a two-tiered medicine in Canada, it's not rich and poor, it's urban versus rural."1 This dramatic statement emphasizes the extent of the current health care gap between urban and rural areas of Canada, a problem that was addressed in the Kirby Panel Report2 and the more recently released Romanow Commission Report.3 In this paper I discuss how these 2 bodies approached the problem and, how the federal government budget of 20034 dealt with the issue and the need to go beyond the current situation in order to address the rural and remote health care issues.

The occasional palliative care patient: lessons we have learned
Len Kelly, Theresa O'Driscoll

Palliative care is an ideal and creative part of rural general practice. It's an opportunity for deepening relationships with families and patients, and a healthy challenge for our medical skills. Rural physicians are used to being "Jacks of all Trades." Palliative care falls within our role of treating patients throughout their life cycle. As with other neglected areas of clinical care, palliative care is the focus of extra training initiatives. Extra training is fine for those who take the courses, but it shouldn't send the message that it's a skill beyond the scope of all rural physicians called upon to help their patients die comfortably, often in their own homes.

SRPC Policy Paper on Regionalization, Spring 2004
Jill Konkin, David Howe, Trina Larsen Soles

All provincial governments in Canada except Ontario have embraced regionalization of health care services. In some provinces this has included a broad range of services, such as acute care, home care, public health, mental health. In other provinces regionalized services have been more limited. Some provinces have made many smaller units, and others have made fewer larger units, but all exercises in regionalization have driven a centralization of services. This has had significant impact in rural communities.


Journal of Rural Health

Contents: 2004; 20 4: Fall
Issue includes:

The Environmental Context of Patient Safety and Medical Errors
Douglas Wholey, Ira Moscovice, Terry Hietpas, and Jeremy Holtzman

The environmental context of patient safety and medical errors was explored with specific interest in rural settings. Special attention was paid to unique features of rural health care organizations and their environment that relate to the patient safety issue and medical errors (including the distribution of patients, types of adverse events associated with learning, information flows, triage and transfer decisions, and culture of safety). Relevant organizational theories and strategies for medical error reduction and prevention in rural health care settings were identified. Financial and technical assistance are needed to support the systematic collection of data from rural hospitals and other entities and to enhance relevant patient safety practices for rural America.

Assuring Rural Hospital Patient Safety: What
Should Be the Priorities?

Andrew F. Coburn, Mary Wakefield, Michelle Casey, Ira Moscovice,
Susan Payne, and Stephenie Loux

Context: Since reports on patient safety were issued by the Institute of Medicine, a number of interventions have been recommended and standards designed to improve hospital patient safety, including the Leapfrog, evidence-based safety standards. These standards are based on research conducted largely in urban hospitals, and it may not be possible to generalize them to rural hospitals. Purpose: The absence of rural-relevant patient safety standards and interventions may diminish purchaser and public perceptions of rural hospitals, further undermining the financial stability of rural hospitals. This study sought to assess the current evidence concerning rural hospital patient safety and to identify a set of rural relevant patient safety interventions that the majority of small rural hospitals could readily implement and that rural hospitals, purchasers, consumers, and others would find relevant and useful. These interventions should help rural hospitals prioritize patient safety efforts. Methods: As background, we reviewed literature; interviewed representatives of provider, payer, consumer, and governmental groups in 8 states; and calculated patient safety indicator rates in rural hospitals using the Agency for Healthcare Research and Quality's Health Care Cost and Utilization Project National Inpatient Sample. Based on the research literature and patient safety recommendations from national organizations, we developed a list of potentially important patient safety areas for rural hospitals. The rural relevance of these safety interventions was evaluated by a national expert panel in terms of the frequency of the problem, ability to implement, and the internal and external value to rural providers, purchasers, and consumers. Findings: The limited available research suggests that patient safety events and medical errors may be less likely to occur in rural than in urban hospitals.We identified 9 areas of patient safety and 26 priority patient safety interventions relevant to rural hospitals. Conclusions: Many of the identified areas of patient safety and interventions are relevant to all types of hospitals, not just rural hospitals. However, some areas, such as transfers, are especially relevant to rural hospitals. The challenges of implementing some interventions, such as 24/7 pharmacy coverage, are significant given workforce supply and financial problems faced by many small rural hospitals. The results of this study provide an important platform for further work to test the validity and effectiveness of these interventions.

Quality Improvement Strategies and Best
Practices in Critical Access Hospitals

Michelle M. Casey, and Ira Moscovice

Context: Critical access hospitals (CAHs) face many challenges in implementing quality improvement (QI) initiatives, which include limited resources, low volume of patients, small staffs, and inadequate information technology. A primary goal of the Medicare Rural Hospital Flexibility Program is to improve the quality of care provided by CAHs. Purpose: This article describes key quality improvement initiatives for a national sample of CAHs that are actively involved in implementing quality-related initiatives in collaboration with support hospitals and statewide organizations. Methods: Researchers conducted a national telephone survey of 72 CAHs and 2 in-depth case studies of CAHs. Findings: The survey and case studies demonstrate that many CAHs are successfully implementing QI activities, including patient safety initiatives, improvements in overall QI processes and peer review processes, and implementation of QI projects focused on treatment of 1 or more specific diseases. The CAHs are involved with multiple external organizations in these activities. The administrators of the 2 case study CAHs have made QI a priority for their hospitals; ensured that resources are available for QI activities; and worked with their support hospitals, statewide organizations, and other CAHs to develop and implement rural-relevant QI initiatives. Conclusions: Cost-based Medicare reimbursement has been a key factor in the ability of CAHs to fund additional staff, staff training, and equipment to improve patient care. The commitment of hospital leaders and key staff is a crucial factor in moving QI initiatives forward in CAHs.

Translating Research Into Practice: Voluntary Reporting of Medication Errors in Critical Access Hospitals
Katherine J. Jones, Gary Cochran, Rodney W. Hicks, and Keith J. Mueller

Context: Low service volume, insufficient information technology, and limited human resources are barriers to learning about and correcting system failures in small rural hospitals. Purpose: This paper describes the implementation of and initial findings from a voluntary medication error reporting program developed by the Nebraska Center for Rural Health Research (NCRHR) to overcome these barriers in 6 Nebraska critical access hospitals (CAHs). Methods: Participating Nebraska CAHs mailed copies of medication error reports to theNCRHR monthly for entry into a database. Quarterly summaries enabled each CAH to compare its reports by severity, type, phase of the medication use process, contributing factors, and causes to those of its peers and MEDMARXSM, a national medication error reporting program. Workshops emphasized learning from the reported errors by identifying system sources of variation in medication use and initiating change to achieve best practices. Findings: Similar to MEDMARX, 99% of medication errors reported by 6 Nebraska CAHs were not harmful, reported errors most often originated in the administration phase, and the most common error type was omission. The CAHs reported significantly smaller proportions of ''nearmiss'' errors and errors originating in the prescribing phase than in MEDMARX. Conclusions: By collaborating with CAHs, an academic medical center, and a national reporting program, the NCRHR is translating the Institute ofMedicine's recommendation for voluntary error reporting into practices that allow CAHs to learn about and improve their medication use systems. However, limited presence of pharmacists inCAHs is a barrier to implementing double checks and learning from system failures in the medication use system.

What Would Be the Effect of Referral to High-Volume Hospitals in a Largely Rural State?
Marcia M. Ward, Mirou Jaana, Douglas S. Wakefield, Robert L. Ohsfeldt, John E. Schneider, Thomas Miller and Yang Lei

Context: Volume of certain surgical procedures has been linked to patient outcomes. The Leapfrog Group and others have recommended evidence based referral using specific volume thresholds for nonemergent cases. The literature is limited on the effect of such referral on hospitals, especially in rural areas. Purpose: To examine the impact of evidence-based referral by volume standard for 5 hospital procedures (abdominal aortic artery repair, coronary angioplasty, coronary artery bypass graft, esophageal cancer surgery, and pancreatic resection) in a largely rural state. Methods: Healthcare Cost and Utilization Project Iowa State Inpatient Dataset was analyzed to identify hospitals meeting the volume standard versus those not meeting the standard. Findings: Relatively few hospitals perform these procedures in Iowa. Hospitals performing the procedures at a volume above the threshold standard set by the Leapfrog Group tend to be larger, receive more transfers from other hospitals for these procedures, and perform fewer of these procedures on an emergency basis. In Iowa, hospitals that met the volume standard did not differ from hospitals that did not meet the volume standard in risk-adjusted mortality rates. The impact of evidence-based referral would be substantial in terms of travel time for some procedures (ie, coronary artery bypass graft, pancreatic resection, and esophageal cancer surgery) and produce considerable lost revenue for some hospitals. Conclusions: Evidence-based referral would be associated with substantial burden for some patients and hospitals in Iowa. This negative impact does not appear to be offset by improvement in in-hospital mortality rates. These initial findings suggest that there are a number of issues that need to be considered, especially in a rural state, before evidence-based referral is embraced as a means to enhance patient outcomes.

Applied Strategies for Improving Patient Safety: A Comprehensive Process To Improve Care in Rural and Frontier Communities
John M. Westfall, Douglas H. Fernald, Elizabeth W. Staton, Rebecca VanVorst, David West, and Wilson D. Pace

Context: Medical errors and patient safety have gained increasing attention throughout all areas of medical care. Understanding patient safety in rural settings is crucial for improving care in rural communities. Purpose: To describe a system to decrease medical errors and improve care in rural and frontier primary care offices. Methods: Applied Strategies for Improving Patient Safety (ASIPS) was a demonstration project designed to collect and analyze medical error reports and use these reports to develop and implement interventions aimed at decreasing errors. ASIPS participants were clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). This paper describes ASIPS in HPRN. Findings: Fourteen HPRN practices with a total of 150 clinicians and staff have participated in ASIPS. Participants have submitted 128 reports. Diagnostic tests were involved in 26% of events; medication errors appeared in 20% of events. Communication errors were reported in 72%. Two learning groups developed ''Principles for Process Improvement'' for medication errors and diagnostic testing errors. Several safety ''alerts'' were issued to improve care, and 2 interventions were implemented to decrease errors. Conclusions: A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in rural primary care settings. Information from reports can be used to identify processes that can be improved.

Organization of Care for Acute Myocardial Infarction in Rural and Urban Hospitals in Kansas
Edward F. Ellerbeck, Arvind Bhimaraj, and Denise Perpich

Context: One in 4 Americans lives in a rural community and relies on rural hospitals and medical systems for emergent care of acute myocardial infarctions (AMI). The infrastructure and organization of AMI care in rural and urban Kansas hospitals was examined. Methods: Using a nominal group process, key elements within hospitals that might influence quality of AMI care were identified, including personnel, equipment, organizational systems, and quality improvement activities. These elements were included in a survey of 45 rural and 12 urban Kansas hospitals. Findings: Though emergency 911 systems were widely available in both urban and rural communities, paramedics and advanced cardiac life support were less likely to be available in rural communities. Few rural hospitals were capable of emergent catheterization, angioplasty, or coronary artery bypass surgery; cardiologists, though readily available by phone, were rarely available on-site. Nevertheless, most rural ambulances could not bypass local hospitals. Most rural hospitals transferred the vast majority of their patients to urban medical centers within an average distance of 78 miles. Standardized protocols were used for emergent AMI care in 67% of urban and 62% of rural hospitals. Hospitals included aspirin in 53% and beta-blockers in 28% of either protocols or standing orders. Conclusions: Although faced with more limited resources, some rural hospitals, like their urban counterparts, have implemented protocols to address emergent care of AMI patients. Nevertheless, many of these protocols omit crucial aspects of AMI care. Rural and urban hospitals should jointly develop systems that assure consistent, rapid delivery of AMI care.

Measuring Rural Hospital Quality
Ira Moscovice, Douglas R. Wholey, Jill Klingner, and Astrid Knott

Context: Increased interest in the measurement of hospital quality has been stimulated by accrediting bodies, purchaser coalitions, government agencies, and other entities. Purpose: This paper examines quality measurement for hospitals in rural settings. We seek to identify rural hospital quality measures that reflect quality in all hospitals and that are sensitive to the rural hospital context. Methods: We develop a conceptual model for measuring rural hospital quality, with a focus on the special issues posed by the rural hospital context for quality measurement. With the assistance of a panel of rural hospital and hospital quality measurement experts, we review hospital quality measures from national and rural organizations for their fit to rural hospitals. Findings: Based on this analysis, we recommend an initial core set of quality measures relevant for rural hospitals with less than 50 beds. This core set of 20 measures includes 11 core measures from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) related to community acquired pneumonia, heart failure, and acute myocardial infarction; 1 measure related to infection control; 3 measures related to medication dispensing and teaching; 2 procedure-related measures; 1 financial measure; and 2 other measures related to the use of advance directives and emergency department monitoring of trauma vital signs. Conclusion: Based on the special measurement needs posed by the rural hospital context, we suggest avenues for future quality measure development for core rural hospital functions (eg, triage, stabilization, and transfer, and emergency care) not considered in existing quality measurement sets.

Intensive Care Unit Utilization and Interhospital Transfers As Potential Indicators of Rural Hospital Quality
Douglas S. Wakefield, Marcia Ward, Thomas Miller, Robert Ohsfeldt, Mirou Jaana, Yang Lei, Roger Tracy, and John Schneider

Context: Obtaining meaningful information from statistically valid and reliable measures of the quality of care for disease-specific care provided in small rural hospitals is limited by small numbers of cases and different definitive care capacities. An alternative approach may be to aggregate and analyze patient services that reflect more generalized care processes. Purpose: To evaluate the applicability of intensive care unit (ICU) utilization and interhospital transfers as potential indicators of quality in rural hospitals. Methods: Secondary data analysis of ICU utilization and interhospital transfer practices in Iowa's Critical Access (CAH), rural, rural referral, and urban hospitals. Findings: Rural hospitals have fewer resources, provide a more limited range of definitive care services, and rely to a greater extent on transferring patients to other hospitals capable of providing the required definitive care. Examining ICU utilization and interhospital transfer patterns we found (1) that lower percentages of patients receive ICU care in smaller facilities; (2) higher transfer rates for both ICU and non-ICU patients in CAH hospitals; (3) shorter average lengths of stay for ICU patients from smaller hospitals who were transferred; and (4) lower mortality rates for CAH and rural hospital ICU patients. Conclusions: Examining ICU utilization and interhospital transfer patterns offers potential insights into rural hospital quality measurement and comparisons.


Australian Journal of Rural Health

2003; 12 (4)
issue includes

Accuracy and clinical usefulness of the near-patient testing CoaguChek S international normalised ratio monitor in rural medical practice
Shane L. Jackson, Luke R. Bereznicki, Gregory M. Peterson, Katherine A. Marsden, David M. L. Jupe, Janet H. Vial, Rohan L. Rasiah, Gary Misan, Sharon M. Williams

Objective: To compare the accuracy and clinical usefulness of the near-patient testing CoaguChek S INR monitor in rural medical practice.
Design, setting and main outcome measures: General practices were identified through Australian university departments of rural health. Study investigators trained general practitioners and/or practice nurses in the use of the CoaguChek S INR monitor. General practices obtained a fingerprick sample for testing with the INR monitor to compare with conventional pathology testing for accuracy. An evaluation questionnaire was administered to users of the machine to assess ease of use and clinical usefulness.
Results: A total of 169 patients from 15 general practice sites provided 401 paired (CoaguChek S and laboratory) INR results. The CoaguChek S was found to be accurate when compared to laboratory INR (r = 0.89), despite complicating variables such as multiple users of the monitor and multiple laboratories used for comparison with the CoaguChek S INR. Overall, 88% of dual INR measurements were within 0.5 INR units of each other. For laboratory INR 1.9, 2.0 3.5 and 3.6, 97%, 90% and 57% of readings were within 0.5 INR units, respectively. Clinical agreement occurred 93% and 90% of the time against published expanded and narrow criteria, respectively.
Conclusions: The routine use of near-patient testing, with appropriate training and quality assurance programs, has the potential to increase the safety and efficacy of warfarin therapy in rural and remote communities.

Dental visits in older Western Australians: A comparison of urban, rural and remote residents
Claire Adams, Linda Slack-Smith, Ann Larson, Martin O'Grady

Objective: It has been reported that the aged in rural areas may not access regular dental care. The aim of this study was to describe dental visits for those 60 years of age and older living in urban, rural and remote locations in Western Australia and to determine factors associated with such visits. The main outcome was having had a dental visit in the previous 12 months.
Design: A cross-sectional telephone survey was conducted.
Setting: Urban, rural and remote locations in Western Australia.
Subjects: A total of 2100 participants, 60 years of age and older.
Results: The present study demonstrated that people in rural and remote areas of Western Australia had a longer time since their last dental visit than people in urban areas. Within each sex, age, country of birth, income, occupation and education group, the highest proportion of people having attended a dentist in the previous 12 months was in urban areas and the lowest was in remote areas. Controlling for sex, age, education and oral health status, compared to urban residents, rural residents were 14% less likely to have seen a dentist and remote residents were 27% less likely.
Conclusion: The present study demonstrated that for the aged sector of the Western Australian population, geographical location is a major factor in the frequency of use of dental services and the reasons for dental visits. This raises concerns that improvement of oral health by prevention and early detection of tooth and gum problems is less likely to occur in rural and remote areas than in urban areas.

Hepatitis C education needs of rural general practitioners working in northern New South Wales
John Fraser, Christian Alexander, Karin Fisher

Objective: To assess hepatitis C continuing medical education (CME) needs of GPs working in rural northern New South Wales (NSW).
Methods: Anonymous reply paid postal questionnaires sent to all 634 GPs working in northern NSW in August 2000 with a follow-up in September 2000. Data were analysed using descriptive and 2statistics for association.
Results: Two hundred and ninety-two GPs replied (response rate 46.1%). Sixty-three per cent of respondents were aware of hepatitis C management protocols. Hepatitis C information was most accessed by reading written material (93%), attending seminars (63%) and using the protocol (57%).
Rural GPs need to balance hepatitis C education with other competing topics. We found restricted access to CME in rural areas with GPs requesting a greater range of delivery modes.
Conclusions: GPs have an increasing role in hepatitis C management. Hepatitis C CME must be balanced against GPs' patient load, interest and competing learning needs.

Interactive videoconferencing system for rural health education: A preliminary report
Jonathan Newbury, Warren McKenzie

Object: To establish a videoconferencing network in a new Rural Clinical School.
Design: A report on choosing hardware and connecting multiple sites simultaneously.
Setting: Rural South Australia.
Subjects: Undergraduate medical, nursing and allied health students.
Interventions: None.
Main outcome measures: Establishment of an effective multisite, dual mode videoconferencing system.
Results: The choice of hardware was simple, but acquiring adequate broadband connection between sites proved difficult.
Conclusions: Multi-site meetings for academic and administrative purposes are now routine. Evaluation of the effectiveness of medical education delivery will occur throughout 2004.

Palliative care by nurses in rural and remote practice
John P. Rosenberg, Debbie F. Canning

Objective: To evaluate the experiences of a group of rural and remote nurses in providing palliative care and to discuss the implications of this evaluation for the development and implementation of professional support strategies.
Design: Semi-structured survey comprising 23 items measuring perceptions of the nature of rural and remote practice, the provision of palliative care in these settings and the appropriateness of various professional development strategies; as well as 12 open-ended questions to obtain qualitative descriptions relating to key concepts in rural and remote practice.
Setting: Rural and remote communities in the Southern zone of Queensland Health.
Subjects: Thirty-one registered and enrolled nurses, all female, who attended a two-day professional development workshop.
Main outcome measures: Identification of characteristics of, barriers against and strategies to support the practice of palliative care in rural and remote communities.
Results: High levels of agreement with key statements relating to issues evident in contemporary literature regarding rural and remote nursing practice; qualitative descriptions show congruence with key statements.
Conclusions: This evaluation demonstrated congruence between the challenges faced by this group of nurses and those reported in the literature. These nurses identified the importance of peer networking as an integral part of their work, which enhanced their potential as rural and remote palliative care providers.



[Norwegian medical journal for general practice and public health] [in Norwegian]
Contents 2004: 5

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